Transcript CHILDBIRTH AT RISK

CHILDBIRTH AT RISK
Chapter 21
PSYCHOLOGICAL DISORDERS:
BEHAVIORS IN LABOR
• Depression: decreased ability to concentrate, or
process information; feeling overwhelmed and
hopeless
• Bipolar disorder: may be depressed or hyper
excited
• Anxiety disorder: chest pain SOB, faintness, fear
• Clinical therapy goals: decrease anxiety, maintain
orientation to reality, promote optimal
functioning in labor
HYPERTONIC LABOR
DYSTOCIA
• Characteristics: increased contraction frequency
and uterine resting tone; prolonged latent phase
• Implications: prolonged labor and discomfort;
reduced uteroplacental exchange resulting inn
nonreassuring fetal status
• Prolonged pressure on fetal head resulting in
molding, caput succedaneum and
cephalohematoma
Clinical therapy for Hypertonic labor
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Bed rest and relaxation measures
Pharmacologic sedation
Oxytocin
amniotomy
HYPOTONIC LABOR
(fewer tan 3 contractions in 10 min)
• Usually in active phase after labor already
established
• Clinical therapy: oxytocin, amniotomy, IV fluids
• Nursing Plan:
– Assess amniotic fluid for meconium
– Monitor VS, FHT, I&O, minimize SVE, assess for
signs of infection
– Ambulate, position changes, hydrotherapy relaxation
exercises
PRECIPITOUS LABOR
(less than 3 hours)
• Contributing factors: multiparity, large pelvis,
previous precipitous labor, small fetus in a
favorable position, strong contractions, uterine
hyper stimulation from excess pitocin
• Implications: loss of coping ability, laceration of
cervix, vagina, perineum, postpartum uterine
atony, hemorrhage, fetal stress or hypoxia from
intense uterine ctx. Cerebral trauma from rapid
descent, pneumothorax from rapid descent
NURSING PLAN FOR
PRECIPITOUS LABOR
• Anticipate r/t risk factors (be prepared)
• Frequent monitoring and assess for accelerated
labor progress (intense ctx with little uterine
relaxation), constant nursing attendance
• Prepare for delivery early; keep Dr. informed
• Institute supportive measures for hyper
stimulation: d/c pitocin, side-lying, O2
POSTTERM (more than 42 weeks
gestation)
• Implications:
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Probable labor induction
Risk for large baby
Decreased placental perfusion
Oligohydramnios
Meconium aspiration
Nursing plan for Postterm
Pregnancy
• Teach fetal kick counts antenatally
• Ongoing FHR assessment for signs of cord
compression in labor
• Take corrective action for cord compression due
to oligohydramnios: position change, O2,
amnioinfusion
• Carefully monitor labor progress
• Provide emotional support
FETAL MALPOSITON
• Persistent occiput-posterior (OP)
• Fetal malpresentation:
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Brow
Face
Breech
Transverse
Compound (two presenting parts)
MACROSOMIA (infant weight of
4000g or 8#13oz)
• Predisposing factors: male gender, offspring of
large parents, maternal diabetes, prolonged
gestation, previous large infant, grand
multiparity.
• Implications: dysfuntional labor, soft tissue
laceration during birth, PP hemorrhage, CPD
with subsequent cesarean, meconium aspiration,
shoulder dystocia, brachial plexus injury,
fractured clavicle, asphyxia
NURSING PLAN FOR
MACROSOMIC INFANT
• Continuous EFM; assess for fetal stress (decels)
• Assess for labor dystocia
• Anticipate and assist with emergency measures
during birth as needed such as McRoberts
maneuver, suprapubic pressure, emergency CS
• Anticipate uterine atony postpartum
• Assess newborn for birth trauma
MULTIPLE GESTATION (TWINS
AND MORE)
• Predisposing factors: infertility treatment,
advanced maternal age, African American
ethnicity, multiparity, tall, overweight women
• Early indicators: two gestational sacs on early
US, fundal ht greater than expected, auscultation
of two or more heart rates differing by more
than 10 beats, elevated hCG with severe nausea
and vomiting, elevated alph-fetoprotein
Implications of multiple
gestation
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Increased maternal discomfort
Preeclampsia
Preterm labor
Placenta previa
Abnormal fetal presentation
Dysfunctional labor
Ten times greater perinatal mortality
Increased IUGR, fetal anomalies, cerebral palsy, and
sequelae of prematurity
NURSING PLAN
Prenatal:
educate on lifestyle modifications;
nutrition: 4000 cal daily, 135 g protein, 40-50lb wt gn
increased prenatal visits: weekly NST at 30 wks,
weekly BPP,
educate on danger signs
• Nursing Plan:
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Continuous EFM
18 g IV catheter
Double setup for delivery of newborn
Alert additional staff for help with birth and
newborn care
– Be prepared for CS
FETAL DISTRESS
• Common causes: cord compression,
uteroplacental insufficiency, placental
abnormalities, preexisting maternal or fetal
disease
• Fetal implications: chronic hypoxia, permanent
organ damage, potential emergent CS
• Common initial signs of fetal stress: meconium-stained
amniotic fluid, persistent late decels, persistent severe
variable decels
• Institute Intrauterine Resuscitation measures:
– Correct maternal hypotension and enhance uteroplacental
blood flow
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Change position that improves FHR,
Increase rate of IV
O2 via face mask
Decrease uterine activity: stop pitocin, adm tocolytic
Perform vaginal exam (prolapsed cord?)
ABRUPTIO PLACENTAE
(premature separation of placenta)
• Contributing factors: hydramnios, twins,
smoking, street drugs, trauma
• Significant symptoms: pain, uterine irritability,
and a firm, hard abdomen
• Types:
– Marginal
– Central
– Complete
• Maternal implications: intrapartum hemorrhage,
DIC, ruptured uterus, fatal hemorrhagic shock
• Fetal-neonatal implications: sequelae of
prematurity, hypoxia, anemia, brain damage, fetal
demise
Nursing plan
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Maintain two large bore IV sites
Monitor frequently
Monitor for signs of DIC
Monitor I&O hourly
Measure abdominal girth hourly as well as vital
signs q 15 minutes
• Prepare for CS and neonatal resuscitation
Placenta Previa (placenta implanted
in lower uterine segment
• Categories : total, partial, marginal, low-lying
• Most accurate diagnostic sign is painless, brightred vaginal bleeding.
• Implications: changes in FHR, meconium
staining, fetal hypoxia, cesarean birth, neonatal
anemia
NURSING PLAN
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No vaginal exams!
Assess blood loss, pain, uterine contractions
Continuous external monitoring
Monitor VS and I&O often
Maintain IV access
Provide emotional support
Promote neonatal adaptation: resuscitate as needed,
evaluate H/H, administer oxygen and blood as needed
UMBILICAL CORD PROLAPSE
(cord precedes the fetal presenting
part and gets trapped)
• Implications: extreme maternal emotional stress,
CS, hypoxia, brain damage, fetal death
• Nursing Plan: perform a vaginal exam to
establish engagement or rule out prolapse,
• Maintain hand in vagina to relieve cord
compression, assist to knee-chest position,
prepare for stat CS.
Amniotic Fluid Embolism
• S&S: dyspnea, cyanosis, frothy sputum, chest
pain, tachycardia, hypotension, mental
confusion, massive hemorrhage
• Nursing Plan: summon emergency team, O2,
large bore IV, CPR as needed, prepare for CS
birth, administer blood
HYDRAMNIOS
• Greater than 2000ml of amniotic fluid
• Cause unknown but major fetal anomalies are
present in 20%
• Implications for Mother: shortness of breath,
edema, uterine dysfunction, abruptio placenta,
PP hemorrhage
• Implications for fetus: malformations, preterm
birth, increases mortality rate, prolapsed cord,
malpresentation
OLIGOHYDRAMNIOS
• Amniotic fluid reduced or concentrated to less
than 50% of normal or less than 500 ml at term
• Found in postmaturity , and associated primarily
with fetal renal defects or placental insufficiency
• Implications: dysfunctional labor with slow
progress
• Umbilical cord compression, head compression
• May need amnioinfusion during labor
CEPHALOPELVIC
DISPROPORTION (CPD)
• A contracture or narrow diameter in birth
passage especially if fetus is larger than the
maternal pelvic diameters.
• Implications: Maternal: prolonged labor, arrest
of descent, uterine rupture, forceps-assisted
birth with trauma
• Implications: Fetal: cord prolapse, excessive
molding of head, birth trauma to skull and CNS
Nursing Plan for CPD
• Assess cervical change and fetal descent
frequently
• Continuously monitor FHT
• Be alert for signs of fetal stress
• Assist with optimal positioning during labor
such as squatting, hands and knees
Complications of 3rd and 4th stages
of Labor
• Retained Placenta: beyond 30 minutes after birth
• Lacerations: first, second, third (extends through
the perineal body and involves the anal sphincter
and fourth (extends through the rectal mucosa
to the lumen of the rectum.
• Placenta accreta: the chorionic villi attach
directly to the myometrium of the uterus
Fetal Death
REVIEW
• Dystocia/hypotonic – difficult, often prolonged
labor caused by dysfunctional or uncoordinated
uterine activity
– Irregular in timing, strength or both and arrest
cervical change
– Pharmocologic sedation will frequently stop these
contractions
– If rest doesn’t improve the pattern, labor stimulation
with pitocin may be used if CPD ruled out
• Precipitous birth is not the same as precipitous
labor. Precipitous labor is simply a rapid labor
followed by anticipated birth., Precipitous birth
is unexpected, sudden and often unattended.
• There are both maternal and fetal risks with
precipitous labor
• Implications of postterm primarily stem from
decreasing placental function and concerns abut fetal
size and well-being
• Meconium is more common in postterm pregnancies,
possibly due to fetal maturity, or stress related to
suboptimal placental functioning
• Careful assessment of labor progress is warranted due
to the risk of CPD from macrosomia
MALPOSITION
• Occiput posterior is the most common fetal
malposition
• During labor, 90 to 95% of OP fetuses rotate to
OA position
• Maternal position such as hands and knees may
facilitate fetal rotation and relieve back pain
Malpresentations
• Brow, face, breech shoulder and compound
• Many brow presentations convert to occipital or
face with fetal descent
• Reassure the couple that the edema and bruising
are temporary and will be markedly improved in
3-4 days, though complete resolution may take
several weeks.
• The nurse is frequently the first to recognize
breech presentation through Leopold’s
maneuvers and vaginal exam.
• Footling breech, nurse must be alert for
prolapsed cord. The danger is greater if there is
a small fetus and membranes are ruptured
• If transverse lie persists at term, external
cephalic version may be useful
Macrosomia
• Primary risks are CPD and shoulder dystocia
• Dysfunctional labor or lack of fetal descent
could indicate CPD
• Birth trauma associated with this are:
– Erb’s palsy
– Fractured clavicle
– cephalohematoma
More than one fetus
• Clinical monitoring usually begins in 3rd
trimester and continues until nonreassuring
findings are obtained or birth occurs
Abruptio Placentae
• Separation of normally implanted placenta
• Occurs more frequently in pregnancies with
hypertension and cocaine abuse. Also smoking
and alcohol ingestion are contributing factors
• Clotting disorders (DIC) result when uterine
wall damage and retroplacental clotting from
central separation trigger release of a large
amount of thromboplastin into maternal
circulation
• If separation is mild and pregnancy near term,
labor induction may be feasible
• Signs are painful, board like distended abdomen
and uterine irritability
Placenta Previa
• Signs are painless bleeding. Abdomen is soft
• Management based on gestational age at first
bleeding episode and the amount of bleeding
• No vaginal exams should be done by nurse
• Preterm can usually be managed with bed rest
with bathroom privileges only as long as there is
no bleeding, pain and uterine contractions until
fetus is mature.
Umbilical cord Prolapse
• Compresses the blood vessels to and from the
fetus. Labor ctx further compress the cord
• A drop in fetal heart rate accompanied by
variable decelerations is consistent with prolapse
cord. And a vaginal exam is the best way to
confirm.
• The number one priority is to relieve
compression to allow blood flow to reach fetus.
A c-section is imminent.
Polyhydramnios
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Occurs in 10 to 20% of pregnant diabetics
Major fetal anomalies are present in 20% of cases
Uterine over distention may result in labor
dysfunction and postpartum hemorrhage
Rupture of membranes increases risk of cord prolapse
An abnormally taut abdomen with difficulty palpating
the fetus may be suspicious for hydramnios